,NUR 2502 Final Exam | Multidimensional Care III (2026) Actual Q&A
PDF | Rasmussen College
1. A client with left-sided heart failure reports dyspnea and has crackles in both lungs. What
is the nurse's priority action?
A) Administer IV furosemide
B) Place the client supine
C) Administer oxygen
D) Restrict fluids
Correct Answer: Administer oxygen
Rationale: Oxygenation is the priority according to the ABCs (Airway, Breathing, Circulation).
Crackles indicate pulmonary congestion impairing gas exchange. While furosemide and fluid
restriction address the underlying fluid overload, oxygen addresses the immediate life-
threatening hypoxia.
2. A client taking digoxin has a heart rate of 54 bpm. What should the nurse do?
A) Give the medication
B) Hold the medication
C) Double the dose
D) Administer potassium
Correct Answer: Hold the medication
Rationale: Digoxin should be held if the apical pulse is less than 60 bpm in an adult due to
the risk of bradycardia and digoxin toxicity. The healthcare provider should be notified of the
finding.
3. Which laboratory value requires immediate intervention?
A) Sodium 140 mEq/L
B) Potassium 6.2 mEq/L
,C) Hemoglobin 13 g/dL
D) WBC 7,000/mm³
Correct Answer: Potassium 6.2 mEq/L
Rationale: Hyperkalemia (potassium >5.0 mEq/L) can cause life-threatening cardiac
dysrhythmias. The other values are within normal limits and do not require immediate
intervention.
4. A client with COPD becomes lethargic while on 4 L/min of oxygen. What is the likely
cause?
A) Hypoglycemia
B) CO₂ retention
C) Dehydration
D) Infection
Correct Answer: CO₂ retention
Rationale: Clients with COPD may have a hypoxic respiratory drive. High-flow oxygen can
suppress this drive, leading to hypoventilation, CO₂ retention, and CO₂ narcosis, which
causes lethargy and confusion.
5. A client with chest pain has ST-segment elevation on the ECG. This indicates:
A) Stable angina
B) Myocardial infarction
C) Heart block
D) Pericarditis
Correct Answer: Myocardial infarction
Rationale: ST-segment elevation on an ECG indicates acute myocardial infarction (STEMI)
and requires immediate reperfusion therapy. Stable angina typically does not cause ST
elevation, and pericarditis causes diffuse ST elevation.
, 6. A client with a blood glucose of 42 mg/dL is alert and able to swallow. What should the
nurse administer?
A) IV insulin
B) 15 g of oral glucose
C) Glucagon IM
D) Dextrose IV
Correct Answer: 15 g of oral glucose
Rationale: For a conscious hypoglycemic patient who can swallow, the treatment is 15 g of
rapid-acting oral carbohydrate (e.g., glucose tablets, juice). IV dextrose and IM glucagon are
used for unconscious patients.
7. Which patient should the nurse assess first?
A) Blood pressure 150/90 mmHg
B) Oxygen saturation 85%
C) Glucose 200 mg/dL
D) Temperature 100°F
Correct Answer: Oxygen saturation 85%
Rationale: According to the ABC framework, airway and breathing are the top priorities. An
oxygen saturation of 85% indicates severe hypoxemia and requires immediate intervention.
8. A client on warfarin has an INR of 5.5. What should the nurse do?
A) Administer the dose
B) Hold the medication
C) Increase the dose
D) Encourage leafy green vegetables
PDF | Rasmussen College
1. A client with left-sided heart failure reports dyspnea and has crackles in both lungs. What
is the nurse's priority action?
A) Administer IV furosemide
B) Place the client supine
C) Administer oxygen
D) Restrict fluids
Correct Answer: Administer oxygen
Rationale: Oxygenation is the priority according to the ABCs (Airway, Breathing, Circulation).
Crackles indicate pulmonary congestion impairing gas exchange. While furosemide and fluid
restriction address the underlying fluid overload, oxygen addresses the immediate life-
threatening hypoxia.
2. A client taking digoxin has a heart rate of 54 bpm. What should the nurse do?
A) Give the medication
B) Hold the medication
C) Double the dose
D) Administer potassium
Correct Answer: Hold the medication
Rationale: Digoxin should be held if the apical pulse is less than 60 bpm in an adult due to
the risk of bradycardia and digoxin toxicity. The healthcare provider should be notified of the
finding.
3. Which laboratory value requires immediate intervention?
A) Sodium 140 mEq/L
B) Potassium 6.2 mEq/L
,C) Hemoglobin 13 g/dL
D) WBC 7,000/mm³
Correct Answer: Potassium 6.2 mEq/L
Rationale: Hyperkalemia (potassium >5.0 mEq/L) can cause life-threatening cardiac
dysrhythmias. The other values are within normal limits and do not require immediate
intervention.
4. A client with COPD becomes lethargic while on 4 L/min of oxygen. What is the likely
cause?
A) Hypoglycemia
B) CO₂ retention
C) Dehydration
D) Infection
Correct Answer: CO₂ retention
Rationale: Clients with COPD may have a hypoxic respiratory drive. High-flow oxygen can
suppress this drive, leading to hypoventilation, CO₂ retention, and CO₂ narcosis, which
causes lethargy and confusion.
5. A client with chest pain has ST-segment elevation on the ECG. This indicates:
A) Stable angina
B) Myocardial infarction
C) Heart block
D) Pericarditis
Correct Answer: Myocardial infarction
Rationale: ST-segment elevation on an ECG indicates acute myocardial infarction (STEMI)
and requires immediate reperfusion therapy. Stable angina typically does not cause ST
elevation, and pericarditis causes diffuse ST elevation.
, 6. A client with a blood glucose of 42 mg/dL is alert and able to swallow. What should the
nurse administer?
A) IV insulin
B) 15 g of oral glucose
C) Glucagon IM
D) Dextrose IV
Correct Answer: 15 g of oral glucose
Rationale: For a conscious hypoglycemic patient who can swallow, the treatment is 15 g of
rapid-acting oral carbohydrate (e.g., glucose tablets, juice). IV dextrose and IM glucagon are
used for unconscious patients.
7. Which patient should the nurse assess first?
A) Blood pressure 150/90 mmHg
B) Oxygen saturation 85%
C) Glucose 200 mg/dL
D) Temperature 100°F
Correct Answer: Oxygen saturation 85%
Rationale: According to the ABC framework, airway and breathing are the top priorities. An
oxygen saturation of 85% indicates severe hypoxemia and requires immediate intervention.
8. A client on warfarin has an INR of 5.5. What should the nurse do?
A) Administer the dose
B) Hold the medication
C) Increase the dose
D) Encourage leafy green vegetables
